Scenario: You are an administrator at a health care facility providing a training session for new employees.
Create a training plan using the \”NUR-621 Health Care Reimbursement Training Plan\” template provided that describes how Medicare, Medicaid, and private insurance reimburse health care organizations for their services.
Include two to three references, including your textbook.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
NUR-621 Health Care Reimbursement Training Plan
| Name
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| Unit/Subject
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Health Care Reimbursement Training |
| Training Summary and Focus | The purpose of the training program is to educate new employees about healthcare reimbursement. The central focus of the training is on how Medicare, Medicaid, and private insurance reimburse health are organizations for their services. According to Damery et al. (2021), training healthcare professionals is advantageous in that it improves working practices, promotes safety, and quality, and helps to reduce avoidable harm rates. Therefore, training employees about health care reimbursement will increase their skills in a number of areas. The specific skills that the trainees are expected to learn from the training encompass the adoption of practice behaviors that will not negatively affect hospital reimbursement by Medicare, Medicaid, and private insurance companies. The employees will learn how to avoid behaviors that can lead to medical errors, undesired patient survey results, and unhealthy work environments. |
| Specific Learning Target(s)/Objectives | By the end of the training, the trainees should be able to;
1. Describe the difference between Medicare, Medicaid, and private insurance reimbursement. 2. Explain the specific factors considered by Medicare, Medicaid, and private insurance companies when making reimbursement decisions. 3. Identify their roles in improving Medicare, Medicaid, and private insurance reimbursement.
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| Training Outline | Medicare Reimbursement
· Approaches used to calculate payments: Medicare payment rates have maintained a fee-for-service payment approach. Under this model, Medicare calculates payments for each provider differently based on each particular service rendered. Recent changes intend to tie Medicare reimbursement to the quality of services offered by providers (Cubanski et al., 2016).
· The types of providers covered: Various providers are covered under Medicare reimbursement. The providers include “hospitals that provide inpatient and outpatient services, physicians, skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, hospice agencies, long-term care hospitals, outpatient dialysis facilities, ambulatory surgical centers, inpatient psychiatric facilities, durable medical equipment suppliers, ambulance providers, and laboratories (Cubanski et al., 2016, p.1).” Medicare uses different payment rates for each provider. Reimbursements for these providers are made separately under Medicare.
· Determination and adjustment of base rates: In Medicare reimbursement, a base rate is determined for every specific unit of service rendered. Adjustments are then made on the basis of a number of factors including the clinical severity of patients, policies that are selected by Medicare, and differences in the geographical locations of providers. Medicare payment rates are adjusted every year to consider changes related to inflation (Cubanski et al., 2016).
Medicaid Reimbursement · Components of Medicaid payment: Medicaid reimburses hospitals based on payment rate or base rates that are determined by Medicaid agencies. The rates are determined on the basis of specific healthcare services received by patients. Medicaid combines these payments rates with other supplemental payments (Cunningham et al., 2016). Therefore, the specific components of a Medicaid payment system comprise of a base payment, Disproportionate Share Hospital Payments (DSH) supplemental payments, and non-DSH supplemental payments. Base payments consist of payment rates that are reimbursed to providers through fee-for-service systems. Supplemental payments are separate from base rates and may or may not be linked with specific services (Cunningham et al., 2016).
· Payment rates utilized by Medicaid: Payment rates for Medicaid are either negotiated or set by the government. In this respect, reimbursements that hospitals receive for the healthcare services provided to patients are not a true reflection of the costs of those services or hospital charges. This means that Medicaid reimbursements to hospitals can be either less or more than the costs of services offered. Any reimbursement that is above healthcare costs is a financial advantage for the hospital. However, any reimbursement that is below the costs will always lead to a ‘shortfall’ (Cunningham et al., 2016).
· Effects of Medicaid reimbursements on hospital finances: Medicaid reimbursement has brought about great shifts in the payer mix used by hospitals. Medicaid expansion has caused an increase in Medicaid discharges by hospitals. Additionally, the rise in the number of Medicaid beneficiaries has increased Medicaid reimbursements for hospitals. Medicaid reimbursements have had positive impacts on hospital finances, especially where the reimbursements happen to fall above the costs of healthcare services offered to patients (Cunningham et al., 2016).
· Policy changes that might affect Medicaid payment to hospitals: Variations in base payment rates: Medicaid hospital financing is likely to change greatly when there are any changes in state reimbursement rates for hospitals. The providers that might be affected the most by such changes are safety-net hospitals. The reason is that such hospitals usually serve a large number of Medicaid patients (Cunningham et al., 2016). Variations in Medicaid DSH funding: Hospitals have limits for DSH spending set by the federal government. Under these regulations, hospitals cannot receive DSH payments that exceed these limits. Therefore, any reduction in DSH payment limits for hospitals will negatively affect Medicaid reimbursements for hospitals (Cunningham et al., 2016). Variations in other supplemental payments: Any reforms that affect supplemental payments for hospitals will have an effect on Medicaid reimbursements (Cunningham et al., 2016).
Private Insurance Reimbursement · Price negotiations and cost minimization: Private insurers normally negotiate reimbursement prices with hospitals providers. This approach often disadvantages patients who are insured by private companies that are not willing to pay enough as hospitals or providers rarely accept those payments. Notably, as the number of private insurers increases in the market, private health plans have no choice but to minimize their charges for them to remain competitive in the market. Therefore, the bargaining power of a hospital has an influence on the amount of reimbursement it will receive from a private insurance company (Bruen et al., 2016). |
| List all resources, materials, equipment, and technology you and the employees will use during the training.
· Laptops · Tablets · A projector · Marker pens · Whiteboards · Pamphlets · Printed handouts · Training room/hall · Note-taking tools · To do list/Outline · E-learning resources · Time management tools
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| References | Bruen, B., Docteur, E., Lopert, R., Cohen, J., DiMasi, J., Dor, A., Neumann, P., DeSantis, R., & Shih, C. (2016). The impact of reimbursement policies and practices on healthcare technology innovation. https://aspe.hhs.gov/sites/default/files/private/pdf/188741/ImpactofReimbursementonInnovation.pdf
Cubanski, J., Swoope, C., Boccuti, C., Jacobson, G., Casillas, G., Griffin, S. & Neuman, T. (2016). A primer on Medicare: Key facts about the Medicare Program and the people it covers. https://www.kff.org/report-section/a-primer-on-medicare-how-does-medicare-pay-providers-in-traditional-medicare/ Cunningham, P., Rudowitz, R., Young, K., Garfield, R., & Foutz, J. (2016). Understanding Medicaid hospital payments and the impact of recent policy changes. https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-issue-brief/ Damery, S., Flanagan, S., Jones, J., & Jolly, K. (2021). The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: Evaluation of a care home quality improvement programme in England. International Journal of Environmental Research and Public Health, 18(14), 7581. https://doi.org/10.3390/ijerph18147581. |